Caring for criminals, Part II.

"Into the tape recorder I read my evaluation of this man: 7 saw in him the potential for being a substantial citizen, one whose head was very much "together."' As I spoke into the microphone, I thought I saw a tear rolling down his cheek. It would please me to think my report helped Big Black to reach the street, which he did."

--Dr. Frederick Nesbit in Sweet Auburn: Recollections of a Prison Psychiatrist (Atlantic Beach, N.C.: Eastern Offset Publishing Co., 1999)

Beginnings are crucial in our clinical practices. Every mental health clinician knows how important it is to develop a working therapeutic alliance with a patient from the first moments of the first meeting. A good alliance can help medication compliance, and the strength of the therapeutic alliance may be the most important variable for psychotherapeutic success (Textbook of Psychotherapeutic Treatments, Arlington, Va.: American Psychiatric Publishing, 2009).

Many factors have a bearing on how well this alliance will begin. On the clinician's side, understanding the patient and one's interpersonal skills and empathy are crucial.

The common setting in which this interaction occurs also has a role on the nature of the patient-clinician alliance--whether they meet in a plush outpatient office or the patient is brought into an emergency room by the police often makes a difference for both of them. Whatever the environment, if it is new, it takes a period of adjustment for the clinician to feel comfortable.

Treating patients in the prison environment brings some unique factors into this process. My beginnings at a medium-security prison might be illustrative.

Given my anxiety about entering this system, which I described in last month's column ("Is Prison in my Future? Part I," June 2009, p. 30), it seemed important to me to be oriented by the clinical administrator and a psychiatrist who already worked there.

Of several possible dates, April 10 was selected as my first day. Now, I tend to look for deeper meanings in what appear to be serendipitous connections, or synchronicity, partly because of my psychoanalytic training, which illustrated where deeper, unconscious meanings may exist in the "slips" of everyday life, symptoms, transference, and countertransference. In recent years, that perspective has been supplemented by my interest in possible spiritual meanings.

So what might this date mean for my orientation? Maybe nothing, but this struck me: It was not unlucky Friday the 13th, but it was Good Friday, the day Christians commemorate the crucifixion of Jesus. I wondered how many prisoners identified with Jesus on this day, especially if they felt they were innocent or had been sentenced unfairly. That Friday also fell during the Jewish holiday of Passover, which celebrates freedom and in particular, the Jewish people's flight from captivity in Egypt. Its theme has resonated with many enslaved and oppressed people, and possibly prisoners.

When I arrived at the prison, I was surprised to clear security more easily than one does in an airport.

I did not wear a tie because I had been told not to in case a prisoner got violent and tried to choke me. No chance of using my tie as a kind of Rorschach test here, I thought. But I was soon reassured when I met the clinical administrator, who was wearing a tie.

First Encounters

Soon, I observed my first clinical encounters, and there seemed to be an ethical issue at every turn.

This was a true multidisciplinary clinic, with family practitioners, dentists, psychiatrists, and psychologists housed together. How would we meet the challenge of defining our roles? Patients were not escorted to the psychiatrist's office, so was it safe enough? What about shaking hands with the men? I sat in with a colleague who was told not to. But I thought, if we're in a closed office, an attack was unlikely to start with a handshake. So, when a patient offered to shake my hand at the end of the session, I responded gingerly. He looked a bit surprised, then wished me happy Easter!

These initial encounters seemed emotionally charged. Their intensity reminded me of my first clinical experiences in medical school: fearful, horrific, poignant, painful, and/or gratifying. Would I be able to develop and show enough empathy in this environment?

Navigating the Challenges

Then there were the formulary restrictions--common ethical challenges these days, especially since this is the newest bastion of managed care cost savings and profit. So I wasn't surprised at some of the medications requiring requests for authorization--which I was warned would likely be denied. These were some of the brand name atypical antipsychotics, at least those that cost the most, and some of the newer antidepressants, I felt this wouldn't prevent our ethical obligation for "competent" care, even if I couldn't use my first choice. How well could we predict medication response in a given class of medications?

Somewhat more challenging were the restrictions of using benzodiazepines. This made sense, given the high percentage of alcohol and other drug abuse problems among the patients and other factors. This restriction actually made more ethical sense to me than the blanket refusal of Medicare Part D to pay for benzodiazepines for patients. I also thought it might be better to use propranalol to reduce aggressive behavior, given the likelihood of a history of trauma--mental and physical--in many prisoners.

The biggest ethical challenge was what to do with those who either had or claimed to have adult attention-deficit/hyperactivity disorder. On the one hand, ADHD can contribute to impulsive behavior that, if left untreated, could be one of the reasons someone had gotten into trouble. On the other, it is a difficult diagnosis, especially in the absence of sophisticated psychological testing. Perhaps the biggest concern was that the most effective medications were the stimulants, which can be quite addictive and divertible. I was surprised when I was advised not to start with nonaddictive medications such as Wellbutrin or Strattera. This advice stemmed from the common practice of prisoners saying the medications weren't working--so the clinician would be forced to turn to stimulants.

These formulary considerations were part of a real quality improvement program under the state prison psychiatrist administrator. This was more than anything I had been part of in all my years in my other clinical practice.

I later found the roles of our multidisciplinary staff to be unique. The primary care physicians and nurse practitioners did not prescribe psychiatric medications at all. This made good ethical sense, given what we know about the limited skills many physicians have in this area.

Here's a trick question about health care insurance: Where is there reverse parity? In our prison! Getting mental health care was free, but you had to pay the equivalent of a day's work pay to get medical services unless it was an emergency. I was reimbursed adequately. No-shows were rare, compliance pretty high, and resources available. On the tour I had taken at the start of this journey, we hadn't seen any overcrowding of prisoners. But we did see the top half of men showering, a symbol of the prisoners' lack of privacy.

Insight and Revelation

When I returned home, my wife asked about my day and seemed relieved that I was alive and not shaken. Then suddenly, I felt more shaken than at any other time that day. It took another 2 days to determine what had been lurking in my unconscious and could potentially cause countertransference problems.

I was taking a shower, and, out of the blue, the image of the men showering flashed in my mind. Did the appearance of this prison remind me of Theresienstadt, the Nazi concentration camp? Then I realized that the day before, the Illinois Holocaust Museum had opened in Skokie, ill. Many Holocaust survivors settled in the Chicago suburb after World War II and it made headlines in the 1970s when local neo-Nazis threatened to march on it.

Then images of the prisoners I had seen taking showers metamorphosed into Jews being poisoned in the concentration camp showers. The prison physicians morphed into Dr. Mengele and the other physicians who succumbed to Nazi directions; the prison guards morphed into Nazi SS officers. I remembered, too, that the mentally ill and mentally handicapped were actually killed before the Jews.

Could what I saw in this prison possibly be a front for something worse?

I turned on the water and felt relief. The evidence seemed clear: This prison seems to be a good place to practice psychiatry and provide competent care.

Lessons Learned

Working in the prison has taught me much so far, including things I can use when I am practicing outside of prison. For one, the older antidepressants and antipsychotics definitely still have value. I have not seen this much chlorpromazine used for 25 years. However, in judicious dosing, it has its place.

I've seen more patients diagnosed with antisocial personality disorder than I have in my entire career so far. In trying to reassess them, I concluded that about half of them didn't meet the criteria for the disorder. Some had traits, at best; others seemed to appear antisocial, but more likely were suffering from an impulse control disorder, posttraumatic stress syndrome, ADHD, or even narcissistic personality disorder.

At the core of some of these men there seems to be an unbearable sense of shame, masked by a front of honor, bravado, and pride. If that shame could be recognized and accepted while in prison, could the compensating psychological mechanisms be channeled more productively?

Also, I began to wonder whether I could dress in such a way to develop an alliance with the prisoners. The inmates wore dark green scrub-like tops. Why couldn't I wear a shirt of a similar color? So I did. After a while, a secretary seemed to get my intent: "Dr. Moffic, you'll have to stop wearing that color shirt. I can't tell you from the prisoners!" she said. I explained that it was an attempt to bond with them, and reminded her of the saying, "you can't tell the inpatients from the staff in a psychiatric hospital."

If we provide successful treatment in prison, might the beneficial ramifications be broader than they are in much of everyday clinical practice? If anything we do reduces the propensity for crime and possible reincarceration, not only will the prisoner benefit, but victims of crime will be fewer and the cost to society will be less burdensome. There might be obstacles, but it's possible. I think I'll stay in prison for a while to find out.

DR. MOFFIC is a professor of psychiatry and behavioral medicine, as well as family and community medicine, at the Medical College of Wisconsin, Milwaukee. He can be reached at [e-mail].